You can always press Enter⏎ to continue
ATNG Nutrition Pre-Assessment Form
Hi there, please fill out and submit this form.
53
Questions
START
HIPAA
Compliance
1
Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
2
Occupation
Previous
Next
Submit
Press
Enter
3
Age
*
This field is required.
Age in Years
Previous
Next
Submit
Press
Enter
4
Height
*
This field is required.
Please state how tall you are.
Feet and inches
Previous
Next
Submit
Press
Enter
5
Weight
*
This field is required.
Please state your most recent weight.
Weight in pounds
Previous
Next
Submit
Press
Enter
6
Weight Assessment at our Office
*
This field is required.
Are you comfortable having your body weight assessed at our office?
YES
NO
Previous
Next
Submit
Press
Enter
7
Gender
*
This field is required.
Male
Female
Other
I prefer not to answer this question
Previous
Next
Submit
Press
Enter
8
Is weight loss one of your reasons you are seeking nutritional counseling?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
9
If you are interested in reducing body weight, please select which approach you feel suits your goals
I am not sure what will be the best approach to promote my weight loss goals
I want a strict meal plan that promotes a rapid weight loss
I do not want a strict meal plan; I prefer to make small changes over time that will get me to my goals and produce a sustainable result
I am interested in a very specific diet that I need help with and I will talk to my dietitian about this
I need another approach that is not listed here
Previous
Next
Submit
Press
Enter
10
Please explain your reasons for seeking nutritional counseling. This may include losing weight, managing blood sugar, managing a digestive or gastrointestinal issue, or simply implementing a healthy diet to prevent problems. You may have other reasons. Your answer will help us to identify your specific needs for nutritional counseling.
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
11
Medication
Please list medications you are currently taking. Specify the dose of each medication if you can. Nutritional supplements are addressed in the next question.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
12
Supplementation
Please list Vitamin and/ or Herbal supplements you are currently taking. Specify the dose of each supplement if you know what it is, and also state how often you take the supplement.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
13
Please indicate if you have any of the following conditions:
*
This field is required.
YOUR HEALTH HISTORY
Diabetes
High Cholesterol
Heart Disease
Stroke
Pre-diabetes
PCOS
Gout
High Blood Pressure
Anemia
GERD
Food Allergy
Food Intolerance
Irritable Bowel Syndrome
Constipation
Autoimmune Disease
Hypothyroidism
Cancer
Arthritis
SIBO
Inflammatory Bowel Disease
Obesity
Overweight
Eating Disorder
Fatty Liver Disease
Osteoporosis
Osteopenia
Sleep Apnea
COPD
Other
None
Previous
Next
Submit
Press
Enter
14
Other conditions
Please list any other condition you may have that you would like your nutritionist to know about.
Previous
Next
Submit
Press
Enter
15
Please indicate if anybody in your immediate family has had any of the following conditions.
*
This field is required.
FAMILY HISTORY
Diabetes
Heart Disease
Pre-diabetes
High Cholesterol
Stroke
High Blood Pressure
Cancer
Arthritis
Obesity
Osteoporosis
Hypothyroidism
Other
I do not know my family history
Previous
Next
Submit
Press
Enter
16
Weight History
*
This field is required.
Please provide a brief history regarding body weight. You may include information regarding your highest and lowest adult weight, any previous weight loss methods, or anything else you feel may be helpful such as unintentional weight changes.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
17
Sleep Assessment
*
This field is required.
Sleep patterns can affect your health and your nutritional intake.
Please Select
< 7 hours per night
7 - 9 hours per night
> 9 hours each night
Please Select
Please Select
< 7 hours per night
7 - 9 hours per night
> 9 hours each night
How many hours of sleep do you get per night on average?
Please Select
Yes
No
Sometimes
Please Select
Please Select
Yes
No
Sometimes
Do you fall asleep easily when you go to bed at night?
Please Select
No, I do not wake up at night
I sometimes wake up
Yes, I often wake up
Please Select
Please Select
No, I do not wake up at night
I sometimes wake up
Yes, I often wake up
Do you wake up during the night?
Please Select
Yes
No
Sometimes
Seldom
Please Select
Please Select
Yes
No
Sometimes
Seldom
Do you wake up feeling rested?
Please list anything other information you feel is relevant to your sleeping habits.
Previous
Next
Submit
Press
Enter
18
Energy Levels
*
This field is required.
Please describe your energy levels during the day. Are there any times in the day when you feel a slump in energy levels or feel particularly tired?
Previous
Next
Submit
Press
Enter
19
Tobacco / Nicotine Use
*
This field is required.
Please Select
I have never used tobacco/ nicotine Products
I am a previous smoker, but no longer use tobacco/nicotine products
I am a current smoker and use tobacco/nicotine products.
Please Select
Please Select
I have never used tobacco/ nicotine Products
I am a previous smoker, but no longer use tobacco/nicotine products
I am a current smoker and use tobacco/nicotine products.
Please indicate if you use Tobacco or Nicotine Products
Previous
Next
Submit
Press
Enter
20
Tobacco / Nicotine use/ continued...
How many days, months or years since you last used tobacco or nicotine products?
Previous
Next
Submit
Press
Enter
21
Physical Activity
*
This field is required.
Do you participate in any formal exercise apart from the activity you get from your daily routine
No
Sometimes, but not consistently
Yes, routinely each week
Yes, daily
No
Sometimes, but not consistently
Yes, routinely each week
Yes, daily
Previous
Next
Submit
Press
Enter
22
Physical Activity Assessment
*
This field is required.
This section is used to identify your usual weekly activity level
Please list here the type of exercise you like to do.
How many times per week do you engage in planned exercise
Please state how much time you spend exercising
Previous
Next
Submit
Press
Enter
23
Alcohol Consumption
Please Select
Yes
No
Please Select
Please Select
Yes
No
Do you consume alcoholic beverages, such as wine, beer or liquor?
Please Select
Less than 1-times per week, I seldom consume alcohol
1-3 times per week
3-5 times per week
5 or more times per week
Please Select
Please Select
Less than 1-times per week, I seldom consume alcohol
1-3 times per week
3-5 times per week
5 or more times per week
Please indicate how many times a week you usually consume alcohol .
How many drinks do you consume per drinking occasion?
Please list the types of drinks you prefer, e.g. Wine, Beer, Cocktails, Bourbon, etc.
Previous
Next
Submit
Press
Enter
24
STRESS ASSESSMENT. Stress can affect your health , appetite, and weight. Please describe your typical stress level on a scale of 0 to 10 in the box that follows next, with 0 indicating no stress and 10 indicating severely stressed.
STRESS ASSESSMENT SCALE
Previous
Next
Submit
Press
Enter
25
Stress Level Assessment
*
This field is required.
Please indicate your level of stress on a scale of 0 to 10
Do you think Stress affects your eating/sleeping/exercise habits, if so describe how stress affects you.
How often do you feel stressed?
How do you manage your stress?
Previous
Next
Submit
Press
Enter
26
For Women: Are you postmenopausal?
YES
NO
Previous
Next
Submit
Press
Enter
27
For Women : Are you pregnant or nursing?
YES
NO
Previous
Next
Submit
Press
Enter
28
For Women: Questions related to menstruation
Please Select
Yes
No
Please Select
Please Select
Yes
No
Are your menstrual cycles regular?
Please Select
Yes
No
Please Select
Please Select
Yes
No
Do you suffer from premenstrual symptoms?
Describe your pre-menstrual or menstrual symptoms.
Do you use hormone therapy or contraceptive medication?
Previous
Next
Submit
Press
Enter
29
Vegan Diet?
*
This field is required.
Are you following a strict vegetarian diet that excludes all animal food products?
YES
NO
Previous
Next
Submit
Press
Enter
30
Beverages
*
This field is required.
Please check all the beverages that you usually consume.
Regular Coffee
Energy Drinks
Decaffeinated Coffee
Regular Soda
Hot Tea
Diet Soda
Sweet Tea
Herbal Tea
Unsweet Tea
Fruit Juice
Sport Drinks, like Gatorade
Seltzer Water, unsweetened
Water
Hot Chocolate
Other
Previous
Next
Submit
Press
Enter
31
Do you usually eat Fruit?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
32
Fruit
*
This field is required.
Please check all that apply to you
Fresh Fruit, for example Apples, Bananas, Oranges, Strawberries, Blueberries, etc.
Fruit Juice
Dried Fruit, such as Dried Mango, Raisins, Dried Apples, Dried Prunes, Dates, etc.
Frozen Fruit
Canned Fruit
Other
None
Previous
Next
Submit
Press
Enter
33
Do you Eat Vegetables and/or Salads
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
34
Please select all the forms of vegetables you usually eat
*
This field is required.
Salads
Fresh Vegetables
Canned Vegetables
Frozen Vegetables
Vegetable Juice
Lentils
Beans such as Black Beans and Pinto beans
Lima Beans
Chickpeas OR Garbanzo Beans
Hummus
Edamame Beans
Other
None
Previous
Next
Submit
Press
Enter
35
Milk and Dairy Products
*
This field is required.
Do you use regular Milk and Dairy Products such as cheese and yogurt as part of your usual diet
YES
NO
Previous
Next
Submit
Press
Enter
36
Milk and Dairy Products
*
This field is required.
Please check all that apply to you
Regular Milk, Whole, 2% , 1% , Fat Free or Skim
Cheese, e.g. Cheddar, Swiss, Havati and other hard cheeses.
Yogurt, fruit or plain
Cottage Cheese
Coffee Creamer
Cream OR Half and Half
Ice-cream or Frozen Yogurt
Other
None
Previous
Next
Submit
Press
Enter
37
Red Meat, such as Beef, Pork, Bison
*
This field is required.
Do you eat read meat products?
YES
NO
Previous
Next
Submit
Press
Enter
38
Red Meat
*
This field is required.
Please select all the products you eat as part of your usual eating a habits
Beef
Lamb
Pork
Sausages
Deli Meat
Bison
Bacon
Venison
Other
None
Previous
Next
Submit
Press
Enter
39
Poultry, such as Chicken, Turkey or Duck
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
40
Chicken, Turkey or Duck
*
This field is required.
Please check all that apply to you
Chicken
Duck
Turkey
Deli Meat
Chicken Sausage
Turkey Bacon
Other
None
Previous
Next
Submit
Press
Enter
41
Eggs
*
This field is required.
Do you eat Eggs
YES
NO
Previous
Next
Submit
Press
Enter
42
Fish and Shell Fish
*
This field is required.
Do you usually eat fish and/or shellfish?
YES
NO
Previous
Next
Submit
Press
Enter
43
Fish and Shellfish
*
This field is required.
Please select all the items you usually eat
White Fish such as Tilapia and Cod
Oily Fish such as Salmon
Tuna
Shrimp
Crab
Scallops
Oysters/ Mussels
Other
None
Previous
Next
Submit
Press
Enter
44
Do you eat nuts or nut butters?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
45
Nut and Nut Butters
*
This field is required.
Please check all the foods you usually eat
Nut Butter, for example Peanut Butter or Almond Butter
Nuts, for example Almonds, Cashews, Walnuts
Seeds, for example Sunflower Seeds, Chia seeds, Pumpkin seeds, etc.
Other
None
Previous
Next
Submit
Press
Enter
46
Starch OR Carbohydrate-containing foods
*
This field is required.
Please check all the foods that you usually eat
Bread
Rice
Crackers
Quinoa
Pasta
Corn
Grits
Oatmeal
Granola
Breakfast Cereal
Bagels/ Bread Buns
English Muffins
Chips
Pretzels
Potatoes
Waffles
Sweet Potatoes
Tortillas
Other
None
Previous
Next
Submit
Press
Enter
47
Fats and Oils
*
This field is required.
Please check all the foods that you usually use
Olive Oil
Margarine
Canola OIl
Coconut Oil
Vegetable Oil
Butter
Salad Dressing
Mayonnaise
Avocado
Olives
Other
None
Previous
Next
Submit
Press
Enter
48
Miscellaneous
*
This field is required.
Please check all the foods that you usually use
Sugar
Cookies/ Cakes
Artificial Sweeteners
Candy
Honey/ Syrup/Jam
Chocolate
Soup
Tofu/ Tempeh
Pizza
Other
Previous
Next
Submit
Press
Enter
49
Dietary Restrictions / Inclusions
Please list dietary restrictions that apply to you.
Please describe any cultural or religious restrictions regarding food.
Please list any food allergies or intolerances you have.
Please list any other foods that you do not eat or do not like.
Please list any food you feel you must have included into your meal plan.
Previous
Next
Submit
Press
Enter
50
Do you live alone OR whom do you live with?
*
This field is required.
This question is asked so that we can understand more about how meals are prepared and shared in your home and the logistics involved with grocery shopping, etc.
Previous
Next
Submit
Press
Enter
51
Tracking
Please let us know more about the tracking Tools/ Apps you have used to monitor your food intake or activity
Describe the methods used here
Previous
Next
Submit
Press
Enter
52
Meal Pattern
*
This field is required.
Please check all of the boxes that apply to you
I usually eat Breakfast
I do not usually eat Breakfast
I usually eat Lunch
I do not usually eat Lunch
I usually eat out at Lunchtime
I make or pack my Lunch each day
I tend to snack between meals
I do not snack between meals
I usually eat Dinner
I do not usually eat Dinner
I snack after Dinner
I tend to graze and do not eat structured meals
Previous
Next
Submit
Press
Enter
53
Meals
*
This field is required.
Tell us more about how you get the meals you usually eat.
Please Select
Never
Rarely/ Seldom
Weekly
Daily
Please Select
Please Select
Never
Rarely/ Seldom
Weekly
Daily
How often do you eat foods that have not been prepared at home?
Please Select
Never
2-4 times per month
2-3 times per week
4 or more times per week
Please Select
Please Select
Never
2-4 times per month
2-3 times per week
4 or more times per week
How often do you eat fast food?
Please Select
Never
2-4 times per month
2-3 times per week
4 or more times per week
Please Select
Please Select
Never
2-4 times per month
2-3 times per week
4 or more times per week
How often do you eat out at restaurants?
Do you know how to cook; and do you enjoy cooking?
Where do you usually do your grocery shopping?
Previous
Next
Submit
Press
Enter
54
Tags
Todo
In Progress
Done
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
54
See All
Go Back
Submit